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Diana Princess of Wales Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 6 April 2017

We carried out a follow-up inspection of Northern Lincolnshire and Goole NHS Foundation Trust from 22 to 25 November 2016 to confirm whether the trust had made improvements to its services since our last inspection, in October 2015. We also undertook an unannounced inspection on 8 December 2016.

To get to the heart of patients’ experiences of care and treatment we always ask the same five questions of all services:are they safe, effective, caring, responsive to people’s needs, and well-led? Where we have a legal duty to do so, we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

When we last inspected this trust, in October 2015, we rated the trust overall as ’requires improvement’. We rated safe,effective, responsive, and well-led as ‘requires improvement’. We rated caring as ‘good’. Scunthorpe General Hospital was rated as ‘inadequate’ overall, Diana Princess of Wales Hospital was rated as ‘requires improvement’ overall and Goole District Hospital was rated ‘good’ overall. In community services community adult services was rated as ‘requires improvement’ overall, end of life care was rated as ‘requires improvement’ overall, children’s and young people’s services was rated as good overall with safe rated as ‘requires improvement’ and dental services was rated as ‘good’overall.

Following the inspection in October 2015 there were six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations. These were in relation to staffing, safe care and treatment, dignity and respect, premises and equipment, good governance and need for consent.

The trust sent us an action plan telling us how it would ensure that it had made improvements required in relation to these breaches of regulation. At this inspection we checked whether these actions had been completed.

In November 2016 we inspected:

• Diana Princess of Wales Hospital

• Scunthorpe General Hospital

• Community Adult Services – safe and well led domains

• Community end of life care services – effective, responsive and well led domains

• Community children’s and young people’s services – safe domain

We did not inspect Goole District Hospital as the services provided at this hospital were rated as good in October 2015. We carried out a follow up inspection of community services and looked specifically at the domains that were rated as‘requires improvement’ following the October 2015 inspection.

We rated Northern Lincolnshire and Goole NHS Foundation Trust as Inadequate overall. Safe and well led were rated as‘inadequate’, effective and responsive were rated as ‘requires improvement’ and caring was rated as ‘good’.

We rated Diana Princess of Wales Hospital as requires improvement overall.

Key Findings:

  • Nursing and medical staffing had improved in some areas since the last   inspection. However, there were still a number of nursing and medical staffing vacancies throughout the trust, staff turnover in some areas were particularly high especially in medical care, emergency departments, surgical services, and services for children and young people.
  • The trust had systems in place to manage staffing shortfall as well as escalation processes to maintain safe patient care. However, a number of registered nurse shifts remained unfilled despite these escalation processes and we saw examples of wards not meeting planned staffing levels and high patient acuity not identified appropriately.
  • There had been a lack of improvement since the inspection in 2015, areas of concern had not been fully addressed in a sustained way and there had been deterioration in a number of services. Safety processes were not always adhered to in some services.
  • In 2015, we said that the trust must ensure there is an effective process for providing consistent feedback and learning from incidents. During this inspection learning from incidents remained inconsistent and variable between directorates. Staff we spoke to reported a varying standard of feedback and learning from incidents.
  • Assessing and responding to patient was risk was inconsistent and did not support early identification of deterioration in maternity, surgery and urgent and emergency services. This was particularly evident in the Emergency Department (ED) at Diana Princess of Wales Hospital, where the national early warning scores (NEWS)were not recorded in the majority of records we reviewed.
  • A Paediatric Early Warning Score (PEWS) was used in ED however there was inconsistent documentation of PEWS scores so we were unable to be sure that the identification and escalation of deterioration in a child’s condition would be recognised.
  • The trust used the five steps to safer surgery procedures including the World Health Organisation (WHO) checklist.However, from a review of records and observations of procedures, it was apparent that this was not an embedded consistent process.
  • Mandatory training rates in infection control were variable across the hospital.
  • We found inconsistent practice with regard to resuscitation trolley checks, fridge temperature checks and medication checks across the hospital.
  • We were not assured patients had adequate nutrition and hydration whilst they were in the emergency department for a long period of time.
  • Patient flow through the hospital however remained an issue with a significant number of patients cared for on non-medical or non-speciality wards. A buddy ward system was in place, however there was still confusion regarding which consultant should review which patient. Patients who were moved more than once could be under the care of different consultants during their stay in hospital.
  • Between December 2015 and September 2016 Diana, Princess of Wales (DPoW) hospital had 452 black breaches.However, since the introduction of the ambulance handover team there had been an improvement.
  • Patients requiring pre-assessment prior to surgery were not always assessed according to an effective patient pathway. There remained a large number of ‘on the day’ cancellations for clinical reasons.
  • Referral to treatment times across a number of services showed a deteriorating position and were significantly below the national indicator and slightly below the England average. Patients were not always able to access services for assessment, diagnosis or treatment when they needed them. There were long wait times within surgical services and overall the service was not meeting the national referral to treatment times (RTT) or all cancer performance standards.
  • Emergency department performance was variable and between August 2015 and July 2016 the department did not achieve the target for 95% of patients to be treated, discharged or admitted within four hours.
  • The neonatal intensive care unit (NICU) and Rainforest ward had been closed to admissions on a number of occasions due to capacity or staffing concerns. The paediatric assessment and observation unit (PAOU) was not always available to staff due to adult overflow patients from the emergency department.
  • In 2015 we raised concerns regarding the numbers and reporting processes of mixed sex breaches. The trust had updated the policy for eliminating mixed sex accommodation, which was in line with Department of Health guidance(November 2010). However the trust has continued to report mixed sex breaches in a number of core services. Mixed sex breaches occurred twice in both November 2015 and December 2015 in AMU due to capacity issues and problems with patient flow.
  • The trust participated in national and local audit programmes however trust performance against national performance was mixed across most of the core services with many showing performance that was worse than England averages. There was also variation in patient outcomes between the two hospital sites. Patient outcomes were overall slightly better at DPoW when compared to SGH. Mandatory training and appraisal targets had not been met by some staff groups. This included safeguarding training targets and not all staff had the required level of safeguarding training in place.
  • The endoscopy unit had lost their Joint Accreditation Group (JAG) accreditation in August 2016 due to an audit that was not submitted within the necessary timescales and communication issues.
  • In maternity services we had concerns regarding the completion of the K2 training package (an interactive computer based training system that covered CTG interpretation and fetal monitoring) for midwives and medical staff in maternity.
  • We found poor leadership and oversight in a number of services, notably maternity services, outpatients, surgery and urgent and emergency care. In these services leaders had not led and managed required service improvements effectively or in a timely manner. In addition service leads had tolerated high levels of risks to quality and safety without taking appropriate and timely action to address them.
  • There was variability in the quality of risk registers, not all risk registers accurately reflected the risks in the service and were not always updated and reviewed effectively.
  • Concerns remained regarding the organisational culture. There were a number of themes that emerged from discussions with staff relating to a disconnection still between the executive team and staff, there was a sense of fear amongst some staff groups regarding repercussions of raising concerns and bullying and harassment. Feedback frommanagement teams had a more positive focus.

However:

  • The trust had taken action in some areas since the 2015 inspection, for example the trust had stopped using band 4 nurses awaiting professional registration numbers within the registered nurse establishment.
  • There were improvements in critical care services. The management team were able to articulate a clear vision and governance processes were effective.
  • Infection control processes and cleanliness was satisfactory in the ED.
  • There was a new management team in surgery that were able to demonstrate an understanding of the challenges and the areas that required further improvement. They had only recently come into post and had not had sufficient time to implement the changes required to address the ongoing concerns.
  • An acute physician model had been established on the acute admissions ward, short stay ward and ambulatory care.One of the benefits of this was to improve the four-hour standard in ED by improving patient flow.
  • There was evidence of good multidisciplinary working in most of the services.
  • In critical care patient outcomes, for example, mortality, early re-admissions, delayed and out of hours discharges had improved and were in line with similar units.
  • There were improvements in the ophthalmology service specifically with regard to the cancellation of clinics and clinical oversight of this process.
  • Overall we observed staff treating patients with dignity and respect. Patients told us staff were caring, attentive and helpful. Staff responded compassionately to pain, discomfort, and emotional distress in a timely and appropriate way.

We saw several areas of good practice including:

  • An ambulance handover team, to see ambulance patients and provide an initial assessment, had been introduced and was providing a positive impact on the ambulance turnaround times.
  • An acute physician model had been established on the acute admissions ward, short stay ward and ambulatory care.One of the benefits of this was to improve the four-hour standard in ED by improving patient flow.
  • An online call service run by the infant feeding co-ordinator was being offered to support breast feeding mothers within the community setting.
  • The trust had held 'Dying Matters' roadshows at a number of local venues in May 2016, including supermarkets and community centres. These had been advertised as events to provide advice and sign-posting to members of the public on all aspects of planning end of life care, bereavement, dying, organ donation, and will-writing.The introduction of the domiciliary non-invasive ventilation service by the respiratory nurse team. This allowed patients to be monitored at home and reduces the need for hospital admissions. Home assessments could be completed and information could be downloaded onto computer software.
  • The development of advanced midwifery practitioners and advanced nurse practitioners in gynaecology.
  • The paediatric service used a ‘pants and tops’ system to allow children to feed back on the care they received.Children filled out ‘pants’ templates and said what they did not like, or filled in ‘tops’ templates to say what they did like.However, there were also areas of poor practice where the trust needs to make improvements.

Importantly:

  • The trust must ensure that the service risk registers are regularly reviewed, updated and include all relevant risks to the service.
  • The trust must monitor and address mixed sex accommodation breaches.
  • The trust must continue to improve its paediatric early warning score (PEWS) system to ensure timely assessment and response for children and young people using services.
  • The trust must ensure that, following serious incidents or never events, root causes and lessons learned are identified and shared with staff, especially within maternity and surgery.
  • The trust must ensure that effective processes are in place to enable access to theatres out of hours, including obstetric theatres, and that all cases are clinically prioritised appropriately.
  • The trust must ensure that the five steps to safer surgery including the World Health Organisation (WHO) safety checklist is implemented consistently within surgical services.
  • The trust must ensure there are effective planning, management oversight and governance processes in place,especially within maternity, ED and outpatients. This includes ensuring effective systems to implement, record and monitor the flow of patients through ED, outpatients and diagnostic services.
  • The trust must ensure the proper and safe management of medicines including: checking that fridge temperatures used for the storage of medication are checked on a daily basis in line with the trust’s policy.
  • The trust must ensure that there are effective processes in place to support staff and that staff are trained in the recognition of safeguarding concerns including all staff caring for children and young people receiving the appropriate level of safeguarding training and in outpatient services.
  • The trust must ensure that actions are taken to enable staff to raise concerns without fear of negative repercussions.
  • The trust must ensure that a patient’s capacity is clearly documented and where a patient is deemed to lack capacity this is assessed and managed appropriately in line with the Mental Capacity Act (2005).
  • The trust must ensure that policies and guidelines in use within clinical areas are compliant with NICE or other clinical bodies.

Emergency and Urgent Care

  • The trust must ensure that effective timely assessment and/or escalation processes are in place, including the use of the National Early Warning Score (NEWS), so that patients’ safety and care is not put at risk, especially within ED.

  • The trust must ensure that timely initial assessment of patients arriving at ED takes place and that the related nationally reported data is accurate.

  • The trust must ensure that ambulance staff are able to promptly register and handover patients on arrival at the ED.

  • The trust must ensure that patients are assessed for pain relief; appropriate action is taken and recorded within the patients’ notes.

  • The trust must ensure that patients in ED receive the appropriate nursing care to meet their basic needs, such as pressure area care and being offered adequate nutrition and hydration and, that this is audited.

  • The trust must ensure the checking of controlled drugs and the safe storage of medications used by the ‘streaming’nurse in ED at DPoW hospital are in line with trust policy.

Critical Care

  • The trust must audit compliance with NICE CG83 rehabilitation after critical illness and act on the results.

  • The trust must review and reduce the number of non-clinical transfers from ICU.

Maternity

  • The trust must ensure that effective timely assessment and/or escalation processes are in place, including the use ofthe Modified Early Obstetric Warning Score (MEOWS).

  • The trust must continue to improve obstetric skills and drills training among medical staff working in obstetrics.

  • The trust must continue to improve midwifery and medical staff competencies in the recognition and timely response to abnormalities in cardiotocography (CTGs) including the use of ‘Fresh eyes’.

Children and Young People’s Service

  • The trust must ensure the number of staff who have received training in advanced paediatric life support in line with national guidance and the trust’s own target.

Outpatients and diagnostic imaging

  • The trust must complete the clinical validation of all outpatient backlogs and continue to address those backlogs, prioritised according to clinical need.

  • The trust must continue to take action to reduce the rates of patients who do not attend (DNA).

  • The trust must continue to take action to reduce the numbers of cancelled clinics.

  • The trust must continue to strengthen the oversight, monitoring and management of outpatient bookings and waiting lists to protect patients from the risks of delayed or inappropriate care and treatment.

  • The trust must continue to work with partners to address referral to treatment times and improve capacity and demand planning to ensure services meet the needs of the local population.

There are also areas of poor practice where the trust should make improvements which are detailed at the end of this report.

On the basis of this inspection, I have recommended that the trust be placed into special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 6 April 2017

Effective

Requires improvement

Updated 6 April 2017

Caring

Good

Updated 6 April 2017

Responsive

Requires improvement

Updated 6 April 2017

Well-led

Inadequate

Updated 6 April 2017

Checks on specific services

Maternity and gynaecology

Updated 12 October 2017

  • Emergency equipment was checked in line with trust policies.
  • Patient records were completed to a high standard and had evidence of appropriate risk assessment and escalation when required.
  • Risk registers were displayed in clinical areas and were visible to staff on the unit.
  • The service had completed a review of staffing levels using the Birthrate Plus® midwifery workforce-planning tool.
  • The trust had developed a maternity services escalation policy.
  • The service had developed a pathway to outline how to contact an anaesthetist if women required an epidural.

However;

  • Actual midwifery staffing levels did not always match the planned midwifery staffing levels.
  • Staff told us that sharing information and learning from incidents had improved on the unit. We were not assured that changes in practice had been fully embedded following a further never event relating to a retained swab.

Medical care (including older people’s care)

Requires improvement

Updated 6 April 2017

We rated this service as requires improvement because:

  • There were high numbers of patients cared for on non-medical or non-speciality wards with no reduction in numbers since the last inspection. High numbers of patients were moved between wards late at night due to the demand for beds. The medical review of these patients was variable and when patients were moved between wards, their care would change to a different consultant.
  • Waiting lists for procedures were increasing and some patients we spoke with identified that they had long waits for their appointments.
  • Some patients’ procedures were cancelled on the day because of a lack of time and this had an impact on the patient’s emotional state.
  • There were inconsistencies in the effectiveness and the quality of leadership and as a result the endoscopy unit had lost Joint Advisory Group on Gastrointestinal Endoscopy (JAG) accreditation.
  • The buddying system for medical patients on non-medical wards was not embedded and some staff were confused as to who to contact.
  • Staff did not have regular team meetings where they could formally discuss issues or concerns.
  • The risk register had not been kept up to date consistently through the year.

However:

  • We saw improvements with the recruitment of nurses. As most vacancies had only recently been filled we were not able to see the full benefit of this to the services at the time of our inspection. Staff fill rates for the majority of the wards were within acceptable ranges.
  • Patient outcomes in national audits showed that the site had better outcomes than the England average. Patients had a reduced level of readmission at the site in most admission categories.
  • Most of the patients and relatives felt involved in their care and thought staff were compassionate about the care they provided. This was reflected in the response rate for the Friends and Family Test and the high percentage of respondents that would recommend the medical wards on the site.
  • The number of mixed sex breaches had reduced since the reconfiguration of the service.
  • Staff enjoyed working for the trust and identified that the ward managers and matrons were supportive.

Urgent and emergency services (A&E)

Updated 12 October 2017

  •   We found gaps in resuscitation equipment checklists.
  • We found gaps in the cleaning checklists. However, the department appeared visibly clean and well maintained.
  • We found that the completion of patient records was variable. We saw gaps in pain, nutrition and hydration, falls and pressure damage risk assessments.
  • Staff recorded clinical observations for patients; however, the completion of National Early Warning Scores (NEWS) was inconsistent.
  • We saw limited evidence that staff performed comfort rounds.
  • We found that 22% of shifts were not filled by substantive staff.
  • We also had security concerns regarding the electronic medicine key system for controlled drugs.

However;

  • We found that the medicines used by the streaming nurse were now securely stored in a locked cupboard.
  • We saw that new processes had been implemented to allow oversight of risks and governance including a nursing dashboard. The evidence we found was not always consistent with the information recorded on the nursing dashboard.

Surgery

Requires improvement

Updated 6 April 2017

In the previous CQC inspection in October 2015, we rated the service as requires improvement overall. At this inspection we rated surgery as requires improvement.

  • The directorate did not consistently learn from incidents, or when things could be improved and take appropriate action to improve safety standards as a result. Repeat incidents had been reported and lessons learned had not consistently been implemented to prevent the incident from re-occurrence.

  • The service did not follow national guidelines when assessing patients. Staff did not always book patients needing emergency surgery into theatres in accordance with the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) guidelines. No formal emergency theatre booking policy or protocol was available to enable staff to comply with the guidelines.
  • Services did not always meet patients’ needs. Patients could not always access services for assessment, diagnosis or treatment when they need them. The service had long wait times and overall it did not meet the national referral to treatment times (RTT) or all cancer performance standards. Performance had been worse than the England overall performance since June 2016 and showed a deteriorating trend.
  • The service had a high number of clinical and non-clinical cancellations. From April to June 2016, 102 operations were cancelled for non-clinical reasons. The high number of outlying patients often caused non-clinical cancellations; patients nursed in a different speciality areas. In the same reporting period, 184 operations were cancelled on the day for clinical reasons. Staff did not assess elective surgery patients, who needed pre assessment before surgery, using an effective patient pathway.
  • The service did not consistently have enough qualified, experienced and skilled staff. Ward managers and co-ordinators had to care for one cohort of patients and supervise another as well as their managerial role. Staff shortages affected staff morale. Staff spoke about a lack of support from the site co-ordination team, in relation to movement of staff, staff shortages and moving patients.
  • Performance in national audits was variable. The majority of indicators in the national emergency laparotomy, bowel cancer and national hip fracture audits continued to be below national performance. National audit action plans we reviewed did not always reflect the actions required by the audit performance.
  • Surgical services did not use patient safety tools consistently. The five steps to safer surgery procedures, including the World Health Organisation (WHO) checklist, was not an embedded consistent process. Staff did not complete formal risk assessments for each day case patient for blood clots (Venous thrombosis). Staff did not always complete nutritional assessments.
  • The directorate did not hold specific surgical mortality and morbidity meetings. We reviewed the critical care morbidity and mortality meeting minutes where shared critical care/surgical patients were discussed. However, we did not see evidence that discussion was held specifically for surgical only patients. Although the senior management team said that individual specialities discussed mortality as part of audit meetings, this information was not collated centrally within the directorate.
  • Policies and guidelines in use within clinical areas were not all compliant with National Institute of Health and Clinical Excellence (NICE) or other clinical bodies. Data we reviewed from June 2016 showed that policies within the directorate were 69% compliant with NICE guidance.
  • The majority of fluid balance charts we reviewed were not completed accurately; this had been previously highlighted on the matron dashboards.
  • The clinical strategy for surgical services did not make detailed reference to national reports and recommendations, the trust values and strategy, or have clear deadlines for actions.
  • The service had a high number of out of hours transfers, after 8pm. On three occasions we saw records, which showed patients being transferred into surgical beds at 1am. This disrupted surgical patient sleep and decreased the number of beds available for elective surgical inpatients.
  • We saw no evidence of the service engaging with patient representatives or staff to improve services.
  • Surgery did not meet the trust target for mandatory training or appraisals. Overall training rates were 82% but individual training modules, such as resuscitation, rates were much lower at 67%. Although the number of staff receiving regular appraisals had increased, this was still below the trust target.

However:

  • The trust had taken action since the 2015 inspection, and had stopped using band 4 nurses awaiting professional registration numbers within the registered nurse establishment.
  • We observed positive interactions between patients and staff. The majority of patients we spoke with were happy with the care they received.
  • Appraisal rates had improved since the 2015 inspection, however they still remained below internal compliance targets.
  • The directorate now had a surgical vision however, due to changes within the senior management team, detailed timescales and plans for action were not available. The senior management team were aware of the challenges within the directorate and spoke with us about their commitment to improving these.

Intensive/critical care

Good

Updated 6 April 2017

In the previous CQC inspection in October 2015, we rated the service as requires improvement overall.

At this inspection we rated critical care as good because:

  • The service had taken action on most of the issues raised in the 2015 inspection. There was an effective governance process in place with a clear structure for escalation in the directorate and there was evidence of regular review of the risk register and controls in place for the risks.
  • Staff were positive about the recent changes to the senior management team, morale had improved, staff were happy in their work and felt supported and valued.
  • There was a clear critical care strategy and staff understood the vision for the service. Staff had begun to rotate between the intensive therapy unit (ITU) and the high dependency unit (HDU) as part of working towards the strategy.
  • Patient outcomes in ITU, for example, mortality, early readmissions and delayed discharges were in line with similar units. HDU had begun to collect Intensive Care National Audit and Research Centre (ICNARC) data to monitor patient outcomes.
  • There was a good track record in safety. There had been no never events, or serious incidents and staff understood their responsibilities to raise concerns and report incidents. The incidents staff reported mainly resulted in low or no harm.
  • Staffing levels and skill mix were planned and reviewed to keep people safe. Staff were supported to maintain and develop their professional skills and mandatory training and safeguarding training rates were near the trust target. A clinical educator had been appointed and was due to commence in post.
  • There had been no complaints about the service in the last 12 months and feedback from patients and relatives was positive about the way staff treated them.

However,

  • Some of the issues raised at the 2015 inspection remained a concern. For example, medical and nurse staffing was still not yet in line with the Guidelines for the Provision of Intensive Care Services 2015 (GPICS). The critical care strategy had plans in place to address this.
  • The rehabilitation after critical illness service was very limited and not in line with GPICS.
  • The number of non-clinical transfers and out of hour’s discharges from ITU were not in line with national guidance and were worse than similar units and the service did not formally monitor the number of patients ventilated outside of critical care.

Services for children & young people

Requires improvement

Updated 6 April 2017

In the previous CQC inspection in October 2015 we rated the service as good overall. At this inspection we rated services for children and young people as requires improvement because:

  • There was a shortage of qualified nursing and medical staff available within the service. Staffing levels did not meet professional guidance and had resulted in services being closed at times of peak demand. There was a lack of senior nursing or medical cover available out of hours and at weekends.

  • Mandatory training and appraisal targets had not been met by all staff groups. This included safeguarding training targets and not all staff had the required level of safeguarding training in place.
  • We were not assured that staff had received the necessary paediatric life support training. This was because data provided by the trust suggested low rates of compliance. However, staff we spoke with told us that they had training in place.
  • The Neonatal Intensive Care Unit (NICU) and Rainforest ward had been closed to admissions on a number of occasions due to capacity or staffing concerns. The Paediatric Assessment and Observation Unit (PAOU) was not always available to staff due to adult overflow patients from the emergency department.
  • Identified risks to the service were not always appropriately recorded or monitored via the risk register.

However:

  • The ward environments were clean and we observed good infection prevention and control techniques. Medicines were stored securely and managed appropriately.
  • Children and their families told us that they received compassionate and dignified care. Parents told us that they understood the care provided to their child and had been involved in decision making. Parents told us that they would be confident in seeking emotional support from staff.

End of life care

Good

Updated 6 April 2017

In the previous CQC inspection in October 2015 we did not inspect end of life care. At this inspection we rated this service as good because:

  • There were low numbers of incidents involving end of life care patients. Staff we spoke with were aware of the duty of candour. All areas that we visited appeared clean and well maintained. The trust had policies and procedures in place for the safe handling and administration of medicines. There were also specific policies available to support staff caring for patients at the end of their life. Patient records were stored securely and record keeping was of a good standard.

  • We saw that trust polices referenced national best practice guidance such as the National Institute for Health and Care Excellence (NICE). This included policies relating to care at the end of life, such as anticipatory drug prescribing for end of life care and the pain and symptom management guidance in the last days of life. We saw evidence of local and national audit participation.
  • We saw that patient’s pain levels, nutrition and hydration needs were assessed and managed effectively. Staff had effective clinical supervision. The trust had been involved in the development of a Northern Lincolnshire multi-agency end of life care strategy; from this, they had identified seven work streams, each of which had developed key performance indicators to measure the trust performance and patient outcomes.
  • We observed staff being compassionate to patients and their families without exception. Patients and relatives we spoke with said that the staff were’ brilliant’ and that the nurses are ‘angels’. We found that staff were sensitive to the needs of the patients and their families. We saw staff caring for patients and their families and speaking to them in a respectful and compassionate manner. We saw that staff provided emotional support to patients and their families.
  • Patients and staff had seven-day access to specialist palliative nurse support. Staff on the wards told us that the SPCT were visible, available and that they regularly reviewed end of life patients and had discussions with patients and their families. Information received from the trust indicated that 86.5% of patients referred to the SPCT were seen within 48 hours. The bereavement team had developed robust processes to help and support bereaved relatives. 82% of patients audited were asked about and achieved their preferred place of care.
  • The trust had been involved in the development of a multi-agency end of life strategy that encompassed the whole of the local health economy. The trust was collating and monitoring quality measures such as patient outcomes through seven strategy sub-working groups. There was a non-executive director with responsibility for end of life care, at board level. Staff reported a positive culture and good working relationships between teams.
  • The trust were supporting the development of staff that were caring for patients at the end of life and we saw good examples of innovation and staff whose purpose was to maintain and improve the services provided to patients and their loved ones.

However:

  • There was limited use of the trust’s last days of life documentation, however the senior team had identified this and were progressing the roll out of the document across the trust.
  • The trust employed less than the National Council for Palliative Care guidance of two whole time equivalent (wte) consultants per 250,000 population, however, there had been no specialist palliative care medical staff in place during our previous inspection therefore this was an improvement. Chaplaincy support was minimal.
  • Low numbers of staff had received a yearly appraisal. The trust did not use an electronic palliative care co-ordination system; however, the development of this was part of the strategy action plan. We were concerned that consent to care and treatment was not always obtained in line with legislation and guidance, including the Mental Capacity Act 2005, for patients who lacked capacity.
  • Not all risks for the service were identified on the risk register for the end of life care service. For example, the delayed roll out of the last days of life document and completion of the deceased patient audit tool were not on the risk register.

Outpatients

Inadequate

Updated 6 April 2017

In the previous CQC inspection in October 2015, we rated this service as inadequate. At this inspection we rated this service as inadequate because:

  • In January 2016 the trust told us that the concerns raised at the October 2015 inspection had been addressed. However, prior to the inspection and following the inspection further cohorts of patients were identified which were not being effectively managed. The trust had failed to address a number of actions, from the October 2015 inspection, in a timely manner.

  • The trust had been slow to implement clinical validation and assessment of risk within waiting lists, across all specialities.
  • The trust had been slow to get to the bottom of waiting list issues and was still discovering patients in unmonitored systems in August 2016.
  • Referral to treatment times were worsening and the trust told us they were unlikely to recover a good position until March 2018.
  • There continued to be large numbers of patients’ overdue follow up appointments or with no due date on the patient administration system.
  • The trust had a continuing high number of cancelled clinics.
  • Effective oversight, monitoring and management of booking patient appointments and waiting list was not evident in all specialities.
  • There was evidence of actual harm and ongoing significant risk of potential harm to patients waiting long periods of time for first and follow up appointments.
  • Safeguarding training compliance for the outpatient staff was below the trust target.
  • There was mixed feedback from staff in a number of roles regarding leadership and an expressed reluctance to raise concerns regarding management or services, for fear of negative repercussions.

However,

  • The trust had taken action to stop cancellation of clinics by non-clinical staff, to improve sharing of lessons from incidents, to ensure safe storage of refrigerated drugs and had improved the facilities and premises in outpatient areas.
  • All radiology staff had received training regarding the ionising radiation (medical exposure) regulations (IR(ME)R 2000).
  • The staff working in outpatients and diagnostic imaging departments were competent and there was evidence of multidisciplinary working across teams and local networks.
  • Nursing, imaging and medical staff understood their roles and responsibilities regarding consent and the application of the Mental Capacity Act.
  • We observed staff in all areas treating patients with kindness and respect and patients were very happy with their care.
  • Concerns and complaints were taken seriously and staff and managers responded positively to patient feedback. There were low levels of complaints for imaging services.
  • The trust performed well against cancer waiting time operational standards.
  • The diagnostic imaging department had a five-year strategy in place to ensure that the department was future proof and had governance processes in place to ensure that risks were mitigated.